SANTA ANA, CA - Federal inspectors documented multiple care and safety violations at St Edna Subacute and Rehabilitation Center during a June 2024 inspection, including medication administration errors, unauthorized oxygen therapy, and failures in post-fall monitoring protocols.
Medication Administration Failures
The facility faced significant medication-related violations affecting patient safety. Inspectors found a 10.34% medication error rate, exceeding the federal maximum of 5%.
During observation, a Licensed Vocational Nurse (LVN) prepared to administer carvedilol to a resident without checking the heart rate first, despite physician orders requiring the medication be held if heart rate dropped below 60 beats per minute. The nurse had already crushed the medication before inspectors intervened to prevent administration.
Additional medication violations included administering Vancomycin intravenously at incorrect infusion rates. The antibiotic was given at 150 ml per hour instead of the prescribed 177 ml per hour. Staff acknowledged the medication should have been administered using an IV pump, which was unavailable at the time.
Blood pressure medications were frequently administered or withheld incorrectly. One resident's carvedilol was given when blood pressure readings indicated it should have been held, while other residents had medications withheld when they should have been administered according to physician parameters.
Oxygen Therapy Without Orders
Inspectors discovered residents receiving oxygen therapy without proper physician orders or care plans. One resident was observed receiving continuous oxygen at 2.5-3 liters per minute for two days following readmission, but no physician's order existed for the therapy.
The oxygen administration violated facility policy requiring physician orders before providing respiratory therapy. When questioned, nursing staff acknowledged no care plan addressed the resident's oxygen use or monitoring requirements.
Respiratory equipment storage and maintenance violations were widespread. Oxygen tubing was found undated, unlabeled, and stored improperly. CPAP masks were left on bedside tables instead of being stored in protective bags when not in use. Humidifiers lacked required date labels indicating when they were changed.
Inadequate Fall Monitoring
The facility failed to complete required post-fall neurological assessments for residents who experienced falls. Federal regulations require systematic monitoring for 72 hours following any fall incident to detect potential complications.
For one resident with cognitive impairment, post-fall neurological checks were incomplete following two separate falls. The required assessments at 15-minute intervals, then 30-minute intervals, then hourly were not performed according to schedule. One assessment was completed more than 21 hours late instead of the required 60-minute interval.
Post-fall monitoring protocols exist specifically because head injuries may not immediately present symptoms. Residents with cognitive impairment face increased risks because they may not be able to communicate symptoms of complications. Proper neurological monitoring can identify changes in mental status, coordination, or other signs indicating the need for medical intervention.
Intravenous Care Deficiencies
The facility failed to properly monitor and maintain IV access devices. PICC lines and midline catheters require specific measurements and assessments to detect complications such as migration, infection, or occlusion.
Inspectors found that external catheter length measurements and arm circumference assessments were not performed as required. One resident's midline catheter dressing showed dried blood and lacked proper dating. These measurements serve as baseline indicators - changes can signal catheter displacement or other complications requiring immediate attention.
IV catheter complications can include serious infections, blood clots, or catheter malfunction. Regular assessment and proper dressing changes reduce infection risks and help identify problems before they become severe.
Fluid Monitoring Inaccuracies
Accurate fluid intake and output monitoring is essential for residents requiring IV therapy or those at risk for dehydration. The facility failed to properly track one resident's fluid intake despite physician orders for monitoring.
Records showed incomplete documentation that failed to account for IV hydration fluids, medication administration fluids, nutritional supplements, and actual urine output volumes. Instead of recording specific fluid amounts, staff documented frequency of voiding rather than actual volumes.
Medical analysis indicates proper fluid balance monitoring is crucial for residents receiving IV antibiotics and hydration therapy. Inadequate monitoring can mask dehydration, fluid overload, or kidney function changes that require immediate medical attention.
Kitchen and Dietary Violations
The facility's food services department faced citations for multiple safety violations affecting 122 residents. Issues included improper food temperature control, inadequate sanitation of preparation surfaces, and equipment maintenance failures.
Specific violations included missing documentation for cooling time-sensitive foods, improper thawing procedures for meats, and inadequate hand washing protocols among food service staff. Kitchen equipment was found unclean, and multiple staff members lacked proper hair covering.
Food safety violations in nursing homes pose particular risks because residents often have compromised immune systems. Improper food handling can lead to foodborne illnesses that may be life-threatening for elderly residents with underlying health conditions.
Regulatory Standards
Federal nursing home regulations require facilities to provide necessary care and services to help residents attain their highest practicable physical, mental, and psychosocial well-being. These violations indicate systemic failures in multiple departments that could impact resident health outcomes.
The facility's medication error rate of 10.34% significantly exceeds acceptable standards. Proper medication administration requires checking multiple parameters including vital signs, drug interactions, and contraindications before giving any medication.
Respiratory care standards require physician orders for all oxygen therapy and proper equipment maintenance to prevent infections. Fall prevention protocols must include comprehensive post-incident monitoring because elderly residents face increased risks for complications including subdural hematomas or other delayed injuries.
The inspection findings suggest the need for enhanced staff training, improved oversight procedures, and systematic quality assurance programs to prevent future violations. Facilities must maintain standards that protect vulnerable residents who depend on professional care for their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2024-06-21 including all violations, facility responses, and corrective action plans.
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